Interactive summary cards
The six pages that follow contain summaries of information about the six disorders most common in primary care.  

These are designed to be used interactively within the consultation, to help the practitioner explain key features of the disorder to the patient and enter into discussion about a possible management plan. They are also contained on the disc and can be printed out and mounted on either side of a piece of A4 card for ease of use.

Mental health in primary care
Alcohol problems
There is one unit of alcohol in:
1⁄2 pint of ordinary strength beer, lager or cider
1⁄4 pint of extra strength beer, lager or cider
1 small glass of white (8 or 9% ABV) wine
2/3 small glass of red (11 or 12% ABV) wine
1 single measure of spirits (30 ml)
Common symptoms
‘High-risk’ 
drinking:	Psychological:	Physical:
Men	á Poor concentration	áHangovers/blackouts
More than three units 	á Sleep problems	á Injuries
alcohol/day 	á Less able to think 	á Tiredness/lack 
(21 units/week)	  	clearly	  	of energy	
	á Depression	á Weight gain	
Women	á Anxiety/stress	á Poor coordination
More than two units 			á High blood pressure
alcohol/day 			á Impotence
(14 units/week)			á Vomiting/nausea
			á Gastritis/diarrhoea
			á Liver disease		
Many have no 			á Brain damage
symptoms but 
are at risk
	á Difficulties and arguments with family/friends
	á Difficulties performing at work/home
	á Withdrawal from friends and social activities
	á Legal problems.
Alcohol problems are treatable
Alcohol problems do not mean weakness
Alcohol problems do not mean you are a bad person
Alcohol problems do mean that you have a medical problem or a lifestyle problem.
What treatments can help?
Both therapies are most often needed:
Supportive therapy: 	Medication: 
á 	to reduce drinking	á 	for moderate to severe withdrawal 
á 	to stop drinking	á 	for physical problems
á 	for stress	á 	consider for relapse prevention.
á 	for prevention of life problems
á 	for education of the family members 
	for support.

Set goals: acceptable levels of drinking
Who?	How many drinks?	How often?
Men	No more than three units	Each day (only for five days/week)
Women	No more than two units	Each day (only for five days/week)
Have two non-alcohol drinking days/week.
Keep in mind: the less the person drinks, the better it is.

	á 	Pregnancy 
	á 	Physical alcohol dependence 
	á 	Physical problems made worse 	Recommendation is  
		by drinking 	not to drink
	á 	Driving, biking	
	á 	Operating machinery
	á 	Exercising (swimming, jogging, etc.)
Determine action: how to reach target levels
á 	Keep track of your 	á 	Engage in alternative	á 	Eat before starting
	alcohol consumption		activities at times that 		to drink 
á 	Turn to family and/		you would normally	á 	Join a support group
	or friends for support		drink (eg when you	á 	Quench your thirst 
á 	Have one or more 		are feeling bored or 		with non-alcoholic 
	non-alcoholic drinks 		stressed)		drinks
	before each drink	á 	Switch to low	á 	Avoid or reduce time
á 	Delay the time of day		alcoholic drinks 		spent with heavy-
	that you drink 	á 	Decide on non-		drinking friends
á 	Take smaller sips		drinking days (2 days	á 	Avoid bars, cafes or  
			or more per week)		former drinking places.
Review progress: are you keeping on track?
Questions to ask:	Progress tips:
á 	Am I keeping to my goals? 	á 	Every week, record how much you 
á 	What are the difficult times?		drink over the week
á 	Am I losing motivation?	á 	Avoid these difficult situations or plan
á 	Do I need more help?		activities to help you cope with them
		á 	Think back to your original reasons for
			cutting down or stopping
		á 	Come back for help, talk to family and 				friends.

Mental health in primary care
Anxiety
Common symptoms
Psychological:	Physical:
á Tension	á Fear of going 	á Trembling	á Muscle tension
á Worry	á crazy	á Sweating	á Nausea
á Panic	á Fear of dying	á Heart pounding	á Breathlessness
á Feelings of	á Fear of losing	á Light headedness	á Numbness
á unreality	á control	á Dizziness	á Stomach pains
			á Tingling sensation
Disruptive to work, social or family life
Anxiety disorders are common and treatable
Anxiety does not mean weakness
Anxiety does not mean losing the mind
Anxiety does not mean personality problems
Severe anxiety does mean a disorder which requires treatment.
Common forms of anxiety
Generalized 
anxiety 
disorder:	Panic disorder:	Social phobia:	Agoraphobia:
á persistent/	á sudden intense	á Fear/avoidance	á Fear/avoidance
á excessive	á fear	á social situations	á of situations 
á worry	á physical	á fear of being	á where escape is 
á physical	á symptoms	á criticized	á difficult
á symptoms.	á psychological	á physical	á leaving familiar
	á symptoms.	á symptoms	á places alone
		á psychological	á physical 
		á symptoms.	á symptoms
			á psychological
			á symptoms.
What treatments can help?
Both therapies are most often needed:
Supportive therapy for:	Medication:
á slow breathing/relaxation	á for severe anxiety
á exposure to feared situations	á for panic attacks.
á realistic/positive thinking
á problem-solving.

About medication
Short term	Side-effects	Ongoing review
á use for severe anxiety	á are important to report	á of medication use
á can be addictive and		á is recommended.
á ineffective when used in	Counselling
á the long term	á (emotional support and
	á problem-solving) is always
	á recommended with medication
Slow breathing to reduce physical symptoms of anxiety
á Breath in for three seconds and out for three seconds, and pause for three seconds before breathing in again.
á Practise 10 minutes morning or night (five minutes is better than nothing).
á Use before and during situations that make you anxious.
á Regularly check and slow down breathing throughout the day.
Change attitudes and ways of thinking
‘My chest is hurting and I can’t	Instead:	‘I am having a panic attack, I
  breathe, I must be having a		  should slow my breathing 
  heart attack.’		  down and I will feel better.’
‘I hope they don’t ask me a	Instead:	‘Whatever I say will be OK, I am
  question, I won’t know what		  not being judged. Others are
  to say.’		  not being judged, why should
		  I be?’
‘My partner has not called as	Instead:	‘They might not have been able
  planned. Something terrible		  to get to a phone. It is very
  must have happened.’		  unlikely that something
		  terrible has happened.’
Exposure to overcome anxiety and avoidance
Easy stage	Moderate stage	Hard stage
(eg walking on own)	(eg lunch with a friend)	(eg shopping with a friend)
á Use slow breathing to control anxiety
á Do not move to the next stage until anxiety decreases to an acceptable level.

Mental health in primary care
Chronic tiredness
Common symptoms
Compared with previous level of energy, and compared to people known to you:
Tired all the time	Tire easily	Tired despite rest
	á Disruptive to work, social and family life
	á Affects ability to carry out routine and other tasks
	á Feelings of frustration.
Chronic Fatigue Syndrome is a much rarer condition, diagnosed when substantial physical and mental fatigue lasts longer than six months and there are no significant findings on physical or laboratory investigation.
Common triggers
Psychological triggers:	Physical triggers:	Medication:
á Depression	á Doing too	á Anaemia	á Thyroid 	á Steroids
á Stress	á much 	á Bronchitis	á disorder	á Antihistamines.
á Worry	á activity	á Asthma	á Influenza
á Anxiety.	á Doing too	á Diabetes	á Alcohol/
	á little	á Arthritis.	á drug use
	á activity.		á Bacterial,
			á viral and
			á other
			á infections.
What treatments can help?
Both therapies are most often needed:
Supportive therapy for:	Medication:
á depression	á for other mental or physical disorders
á worry/anxiety	á anti-depressants are sometimes useful
á stress/life problems	á there are no effective medications specific to
á lifestyle change	á fatigue and the main treatment follows
á level of physical activity.	á psychological lines.

Behavioural strategies
á Examine how well you	á Plan pleasant/enjoyable	á Try to have regular
á are sleeping.	á activities into your week.	á meals during the day.
á Have a brief rest period	á Gradually build up a 	á Try to keep to a healthy
á of about 2 weeks, in	á regular exercise routine.	á diet.
á which there are no	á Do not push yourself too	á Use relaxation 
á extensive activities.	á hard; remember to build	á techniques, for example,
á After the period of 	á up all activities gradually	á slow breathing.
á brief rest, gradually	á and steadily.
á return to your usual
á activities.
Slow breathing for relaxation
á Breath in for three seconds
á Breath out for three seconds
á Pause for three seconds before breathing in again
á Practise for 10 minutes at night (five minutes is better than nothing).
Increase level of physical activity
	A little activity	Daily activities —	Activity that makes
	one or two times a week	not much effort	you out of breath for
	(eg walking)	(eg fast walking,	20 minutes or more,
		shopping, cleaning)	three to five times a week
			(eg jogging)

	Inactive	Some activity	Active

Mental health in primary care
Depression
Common symptoms
Mood and motivation:	Psychological:	Physical:
á Continuous low mood	á Guilt/negative 	á Slowing down or
á Loss of interest or	á attitude to self	á agitation
á pleasure	á Poor concentration/	á Tiredness/lack of
á Hopelessness	á memory	á energy
á Helplessness	á Thoughts of death	á Sleep problems
á Worthlessness	á or suicide	á Disturbed appetite
	á Tearfulness	á (weight loss/increase)
	á Difficulties carrying out routine activities
	á Difficulties performing at work
	á Difficulties with home life
	á Withdrawal from friends and social activities.
Depression is common and treatable
á Depression does not mean weakness
á Depression does not mean laziness
á Depression does mean that you have a medical disorder which requires treatment.
Common triggers
Psychological:	Other:	Illness:	Medication:
Major life events, eg	á Family history	á Infectious	á Antihypertensives
á Recent 	á of depression	á diseases	á H2 blockers
á bereavement	á Childbirth	á Influenza	á Oral
á Relationship	á Menopause	á hepatitis.	á contraceptives
á problems	á Seasonal changes	á Corticosteroids.
á Unemployment	á Chronic medical
á Moving house	á conditions
á Stress at work	á Alcohol and
á Financial 	á substance use
á problems.	á disorders.
What treatments can help?
Both therapies are most often needed:
Supportive therapy for:	Medication:
á stress/life problems	á for depressed mood or loss of interest/
á patterns of negative	á pleasure for two or more weeks and at least 
á thinking	á four of the symptoms mentioned earlier
á prevention of further 	á for little response to supportive therapy
á episode.	á (counselling)
	á for recurrent depression
	á for a family history of depression.

About medication
Effective	Side-effects	Time period
Usually works faster than	must be reported, but	Medication to be
other methods.	generally start improving	continued at least four
Treatment plan	within 7–10 days.	to six months after initial
must be strictly adhered to.	Progress	improvement.
Drugs	á same medication 	Ongoing review
á are not addictive	á should continue	is necessary over the next
á interact in a harmful	á unless a different	few months.
á way with alcohol	á decision is taken by
á improvement takes	á the doctor
á time, generally three	á medication should not
á weeks for a response	á be discontinued without
á do not take in 	á doctor’s knowledge
á combination with	á in case a drug is not
á St John’s wort.	á effective, another drug
	á may be tried.
Increase time spent on enjoyable activities
á Set small achievable, daily  goals	á Plan things to look forward to in future
á for doing pleasant activities	á Keep busy even when it is hard to feel
á Plan time for activities and increase	á motivated
á the amount of time spent on these	á Try to be with other people/family
á each week	á members.
Problem-solving plan
Discuss	Options	Set a time frame
problems with partner/family	Work out possible	to examine and resolve
members, trusted friend or	solutions to solve	problems.
counsellor.	the problems.	Make an action plan
Distance	Pros and cons	for working through the
yourself to look at problems	Examine advantages	problems over a period of
as though you were an	and disadvantages	time.
observer.	of each option.	Review
		Progress made in solving
		problems.
Change attitudes and way of thinking
‘I will always feel this way;	Instead:	‘These feelings are temporary.
  things will never change.’		  With treatment, things will
		  look better in a few weeks.’
‘It’s all my fault. I do not seem	Instead:	‘These are negative thoughts
  to be able to do anything right.’		  that are the result of
		  depression. What evidence
		  for this do I really have?’

Mental health in primary care
Sleep problems
Common symptoms
á Difficulty falling asleep	á Early morning awakening
á Frequent awakening	á Restless or unrefreshing sleep
	á Difficulties at work and in social and family life
	á Makes it difficult to carry out routine or desired tasks.
Common causes
Psychological:	Physical:	Lifestyle:	Environmental:
	Medical 
	problems:
á Depression	á Overweight	á Too hot or too cold	á Noise
á Anxiety	á Heart failure	á Tea, coffee and	á Pollution
á Worries	á Nose, throat and	á alcohol	á Lack of 
á Stress.	á lung disease	á Heavy meal before	á privacy
	á Sleep apnoea	á sleep	á Over-
	á Narcolepsy	á Daytime naps	á crowding.
	á Pains.	á Irregular sleep
	Medications:	á schedule.
	á Steroids
	á Decongestants
	á Others.
What treatments can help?
Supportive therapy is the preferred treatment
Supportive therapy for:	Medication:
á stress/life problems	á for temporary sleep problems
á depression	á for short term use in chronic problems
á worry	á to break sleep cycle.
á changes in lifestyle and sleep habits.

About medication
Short term	Side-effects	Ongoing review
á use for short period	á are important to report.	á of medication use is
á of time.	Harmful	á recommended.
Long-term	á when alcohol and other
á when used in the long	á drugs are used.
á term, there may be
á difficulties stopping,
á leading to dependence.
Lifestyle change strategies
á Try to minimize noise	á Try to avoid eating	á Reduce mental and
á in your sleep 	á immediately before	á physical activity
á environment, if	á going to sleep.	á during the evenings.
á necessary consider	á Try to have your dinner	á Increase your level of
á ear plugs.	á earlier in the evening,	á physical activity
á Try to make sure that	á rather than later.	á during the day; build
á the room in which you	á Don’t lie in bed trying	á up a regular exercise
á are sleeping is not too	á sleep. Get up and do	á routine.
á hot or cold.	á something relaxing until	á Avoid daytime naps,
á Reduce the amount of	á you feel tired.	á even if you have not
á alcohol, coffee and tea	á Have regular times for	á slept the night before.
á that you drink,	á going to bed at night	á Use relaxation
á especially in the	á and waking up in the	á techniques, for
á evenings.	á morning.	á example, slow breathing.
Slow breathing for relaxation
á Breath in for three seconds
á Breath out for three seconds
á Pause for three seconds before breathing in again
á Practise for 10 minutes at night (five minutes is better than nothing).
More evaluation may be needed:
á if someone stops breathing during sleep (sleep apnoea)
á if there is a daytime sleepiness without possible explanation.

Mental health in primary care
Unexplained somatic complaints
Common, unexplained physical problems
á Headaches	á Nausea	á Skin rashes
á Chest pains	á Vomiting	á Frequent urination
á Difficulty in breathing	á Abdominal pain	á Diarrhoea
á Difficulty in swallowing	á Lower back pain	á Skin and muscle
		á discomfort.
Associated worries and concerns
á Associated symptoms and problems
á Beliefs (about what is causing the symptoms)
á Fear (of what might happen).
Physical symptoms are real
A vicious circle can develop:
á Emotional stress can cause physical 
á symptoms or make them worse.
á Physical symptoms can lead to more 
á emotional stress.
á Emotional stress can make physical 
á symptoms worse.
Headaches 		may all be
Difficulty in swallowing	á	caused or made worse
Chest pain/difficulty in breathing		by stress, anxiety
Abdominal pain/nausea/vomiting		worry, anger, depression
Frequent urination/diarrhoea/impotence
Skin rashes
What treatments can help?
Supportive treatment most often needed:
á Effective reassurance, after history and detailed physical examination.
á Management of stress/life problems.
á Treatment of associated depression, anxiety, alcohol problems.
á Learning to relax.
á Avoiding patterns of negative thinking.
á Increasing levels of physical activity.
á Increasing positive/pleasurable activities.

Useful strategies
Reassurance
á Stress often produces physical symptoms or makes them worse.
á There are no signs of serious illness.
á You can benefit from learning strategies to reduce the impact of your symptoms.
Slow breathing to reduce common physical symptoms
(eg muscle tension, hot and cold flushes, headaches, chest tightness)
á Breath in for three seconds and out for three seconds and pause for three seconds before breathing in again.
á Practise 10 minutes morning or night (five minutes is better than nothing).
á Use before and during situations that make you anxious.
á Regularly check and slow down breathing throughout the day.
Change attitudes and way of thinking
‘I can’t understand why the tests	Instead:	‘The pain is real, but I’ve been
  are negative. I feel the pain; it 		  checked out physically and I have
  is probably something really 		  had all the relevant tests. Many
  unusual that I have.’		  other things, such as worry and
		  stress, can cause these pains.’
‘Maybe my doctor has missed	Instead:	‘It is very unlikely that these
  something. I should try 		  doctors have missed something.
  another doctor or better still 		  It is unlikely that a specialist
  a specialist instead.’		  would say anything different.
		  Maybe I should examine  whether
		  stress, tension, or my lifestyle is
		  contributing to the pain.’
‘Why won’t this pain go away. 	Instead:	‘This is not the first time that I’ve
  I’m not feeling well; I’ve 		  thought that there was something
  probably got cancer.’		  terribly wrong and in fact nothing
		  serious developed. I should learn
		  to relax and focus my thoughts 
		  on other things to distract
		  myself from the pains.’
Increase level of physical activity
	A little activity	Daily activities —	Activity that makes
	one or two times a week	not much effort	you out of breath for
	(eg walking)	(eg fast walking,	20 minutes or more,
		shopping, cleaning)	three to five times a week
			(eg jogging)

	Inactive	Some activity	Active